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Related Collections Related Article in Blood Online Social Bookmarking                   What's this?  Previous Article  |  Table of Contents  |  Next Article  Blood, 1 June 2001, Vol. 97, No. 11, pp. 3676-3677 CORRESPONDENCE To the editor: Frequent detection of rising cytomegalovirus antigenemia after allogeneic stem cell transplantation following a regimen containing antithymocyte globulin Cytomegalovirus (CMV) antigenemia assay enables a rapid, quantitative, and noninvasive monitoring of CMV infection, which is widely used as a sign for starting preemptive therapy with ganciclovir after allogeneic hematopoietic stem cell transplantation. Nichols et al1 recently reported that host factors such as the receipt of corticosteroids were important for predicting antigenemia response to treatment with ganciclovir. Referring to their study, we performed an additional analysis with our patients to demonstrate that the inclusion of antithymocyte globulin (ATG) in the conditioning regimen could be another risk factor. Eighty-seven adult patients underwent allogeneic hematopoietic stem cell transplantation in our center between April 1998 and May 2000. Among them, 84 patients (51 bone marrow transplantation and 33 peripheral blood stem cell transplantation) who showed engraftment were analyzed. An antigenemia assay was performed at least once a week after engraftment using the monoclonal antibody HRP-C7 (Teijin, Tokyo, Japan) raised against CMV immediate early antigen, as described in our risk-adapted and response-oriented preemptive therapy.2 High-level antigenemia was defined as a positive result with 10 or more positive cells per 50 000 cells. High-risk patients were defined as those who received transplants from alternative donors, those receiving ATG as part of the preparative regimen, those with grade II-IV acute graft-versus-host disease, and those receiving more than 0.5 mg/kg (methyl-) prednisolone. Ganciclovir was started when high-level CMV antigenemia developed in low-risk patients or when antigenemia at a level of 5 or lower was seen in high-risk patients, with an initial dose of 5 mg/kg twice daily. This was continued for at least one week until the antigenemia began to decrease, and was followed by a 5 mg/kg daily administration while antigenemia remained positive. We used the same definition as Nichols et al for rising antigenemia, which was an increase of 5 times the baseline antigenemia level, in the following analyses. Rising antigenemia was observed in 7 (16%) of the 43 patients who received ganciclovir therapy at 1 (n = 4), 2 (n = 2), or 3 weeks (n = 1). In a univariate analysis, the recipients' age (40 or older) and the use of ATG were identified as risk factors for rising antigenemia (Table 1). The impact of steroid therapy could not be reliably evaluated since only a few patients required persistent/intensive treatment with a dose exceeding 2 mg/kg. A backward stepwise logistic regression analysis revealed that only the use of ATG independently affected the incidence of rising antigenemia. Therefore, our findings further support the possibility raised by Nichols et al that host factors mainly contribute to increasing viral load during preemptive therapy.                                View this table: [in this window] [in a new window]   Table 1. Risk factors for rising antigenemia A total of 8 patients received ATG as part of a nonmyeloablative regimen (n = 5) or to prevent graft rejection in a mismatched transplant (n = 3). The use of ATG for conditioning has been shown to delay immune reconstitution after transplantation.3,4 Nonetheless, we could completely prevent the breakthrough CMV disease in such patients with profound immunosuppression by continuing the induction dosing until the antigenemia level began to decrease. The antigenemia level should be closely monitored even after starting ganciclovir, and the dose should be modified according to the response of the antigenemia level to ganciclovir treatment. Yoshinobu Kanda, Shin Mineishi, Kunihisa Nakai, Takeshi Saito, Ryuji Tanosaki, and Yoichi Takaue Correspondence: Yoshinobu Kanda, Stem Cell Transplant Unit, National Cancer Center Hospital, 5-1-1 Tsukiji, Cho-ku, Tokyo, 104-0045, Japan References 1. Nichols WG, Corey L, Gooley T, et al. Rising pp65 antigenemia during preemptive anticytomegalovirus therapy after allogeneic hematopoietic stem cell transplantation: risk factors, correlation with DNA load, and outcomes. Blood. 2001;97:867-874[Abstract/Free Full Text]. 2. Kanda Y, Mineishi S, Saito T, et al. Preemptive therapy against cytomegalovirus (CMV) diseases guided by CMV antigenemia assay after allogeneic hematopoietic stem cell transplantation: a single-center experience in Japan. Bone Marrow Transplant. 2001;27:437-444[CrossRef][Medline] [Order article via Infotrieve]. 3. Saito T, Kanda Y, Kanai S, et al. Successful nonmyeloablative transplant (NST) using a novel combination of cladribine (2-CdA)/busulfan (BU)/ATG: early full donor chimerism but delayed immune reconstitution [abstract]. Blood. 2000;96:782a. 4. Duval M, Pedron B, Legrand F, et al. Higher dosage of pregraft antithymocyte globulin (ATG) may negatively influence immune reconstitution and survival after stem cell transplantation (SCT) [abstract]. Blood. 2000;96:788a. CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this? Related Article in Blood Online: Rising pp65 antigenemia during preemptive anticytomegalovirus therapy after allogeneic hematopoietic stem cell transplantation: risk factors, correlation with DNA load, and outcomes W. Garrett Nichols, Lawrence Corey, Ted Gooley, W. Lawrence Drew, Richard Miner, Meei-Li Huang, Chris Davis, and Michael Boeckh Blood 2001 97: 867-874. [Abstract] [Full Text] [PDF] This article has been cited by other articles: W. G. Nichols Management of Infectious Complications in the Hematopoietic Stem Cell Transplant Recipient J Intensive Care Med, November 1, 2003; 18(6): 295 - 312. [Abstract] [PDF] R. Vij, J. F. DiPersio, P. Venkatraman, K. Trinkaus, L. T. Goodnough, R. A. Brown, H. J. Khoury, S. M. Devine, A. Oza, S. Shenoy, et al. Donor CMV serostatus has no impact on CMV viremia or disease when prophylactic granulocyte transfusions are given following allogeneic peripheral blood stem cell transplantation Blood, March 1, 2003; 101(5): 2067 - 2069. [Abstract] [Full Text] [PDF] K. M. Sullivan, C. A. Dykewicz, D. L. Longworth, M. Boeckh, L. R. Baden, R. H. Rubin, and K. A. Sepkowitz Preventing Opportunistic Infections After Hematopoietic Stem Cell Transplantation: The Centers for Disease Control and Prevention, Infectious Diseases Society of America, and American Society for Blood and Marrow Transplantation Practice Guidelines and Beyond Hematology, January 1, 2001; 2001(1): 392 - 421. [Abstract] [Full Text] [PDF] This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Rights and Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Kanda, Y. Articles by Takaue, Y. 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